Anxiety, Depression Associated With Increased Chest Pain

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Anxiety and depression are associated with more frequent angina in coronary artery disease patients, researchers report in Circulation: Journal of the American Heart Association.

Angina is chest pain and can include jaw, shoulder, back and arm discomfort. Angina is caused by myocardial ischemia, an inadequate supply of blood-borne oxygen to the heart muscle.

Heart patients with at least moderate anxiety were more than four times likely to have chest pain, while patients with clinical depression were three times more likely to have frequent chest pain. Furthermore, patients with a history of coronary revascularization were twice as likely to have frequent angina.

“This study has identified a high-risk group for angina,” said Mark Sullivan, M.D., Ph.D., senior author of the study and a professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle, Wash. “Patients with daily or weekly angina are highly likely to have significant anxiety and depression.

“We are spending a lot of money on revascularization in these patients. There is a whole other domain that hasn’t received a lot of attention. Anxiety and depression should be assessed in people with frequent angina.”

The study included 191 patients who had established ischemia while undergoing stress testing with myocardial perfusion imaging between April 2004 and 2006 at two Seattle hospitals.

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Researchers found:

• 36 percent reported no angina over the past month;
• 35 percent reported monthly symptoms;
• 30 percent had daily or weekly angina; and
• 44 percent who reported daily or weekly angina had significant anxiety; two-thirds had significant depression.

Average age of the study group was 63 years old, and patients with more frequent angina were more likely to be younger. Patients with more frequent chest pain were more likely to report exertional angina during treadmill testing.

Patients were given the Seattle Angina questionnaire to determine the frequency of angina before stress testing and were given psychosocial assessments including a self reported anxiety and depression questionnaire.

The frequency of angina was strongly linked with anxiety and depression, but the study didn’t establish cause, Sullivan said. “It is unclear whether these psychosocial factors are truly affecting the anginal response to ischemia or if the increased chest pain burden is causing an intensification in psychosocial distress.”

In the United States the primary goal in treating ischemia has been medication and revascularization procedures to reduce myocardial ischemia. In contrast, European physicians use a broader range of treatments for refractory angina, including cognitive-behavioral therapy, medication and rehabilitation programs similar to those used for chronic pain.

“Physicians need to assess patients with frequent angina for anxiety and depression,” Sullivan said. “It’s not all ischemia. There are other very important aspects to angina that can be diagnosed and treated either with psychotherapy or medication. Reducing anxiety and depression may be a cost-effective way to reduce angina.”

The researchers plan to conduct treatment trials in patients with confirmed ischemia who have frequent bouts of angina to determine whether psychotherapy and/or medication will help.

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